Healthcare Provider Details

I. General information

NPI: 1255695177
Provider Name (Legal Business Name): MRS. SUSAN E ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 SOUTHWOODS DR
MONTICELLO NY
12701-7231
US

IV. Provider business mailing address

504 SOUTHWOODS DR
MONTICELLO NY
12701-7231
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-6037
  • Fax: 845-794-4429
Mailing address:
  • Phone: 845-794-6037
  • Fax: 845-794-4429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: